Do the Right Things for the Right Reasons!

Code of Conduct
Do the Right Things for the Right Reasons!
© 2016 by Genesis HealthCare Inc. All Rights Reserved.
Copyright Notice
Genesis Healthcare Inc. Confidential Information
The Genesis Code of Conduct, in its entirety, is proprietary to Genesis Healthcare Inc. and
is protected by the copyright laws of the United States of America.
Under no circumstances may any part of these materials be copied, transmitted,
reproduced, or disclosed to third parties in any form, either electronically or otherwise,
without the prior written consent of Genesis Healthcare Inc.
© Copyright 2016 by Genesis Healthcare, Inc. All Rights Reserved.
NOTE: All images herein are either original art, or pictures obtained from googleimages.com or shutterstock.com
A NOTE ABOUT TERMS USED IN THIS DOCUMENT: All references to the “Company” include Genesis
Healthcare, Inc. and its subsidiaries. For purposes of this Code of Conduct, all references to “covered
persons” include directors, officers and any employees of Genesis Healthcare, Inc. and its subsidiaries and
independent contractors. This Code of Conduct applies to all covered persons. Any waiver of the Code
for executive officers or directors may only be made by the Board of Directors or a Board Committee.
What is the Compliance and Ethics Program?
The Compliance and Ethics Program was created as a structure to teach, support and monitor
these commitments and to help you apply standards of excellence to your specific position.
It provides principles, standards, training, and tools to guide you in meeting your legal, ethical
and professional responsibilities.
The Compliance and Ethics Program comprises Eight Elements which are more fully described in
later sections of this document. Supplemental Compliance Program Standards, which provide
further detail about the Elements, are available for each business line.
ELEMENTS
What is the Genesis Code of Conduct?
It is the foundation of the Genesis Compliance and Ethics Program. The Code of Conduct is a
guide to appropriate workplace behavior - it will help you make the right decisions if you are not
sure how to respond to a situation.
It provides guidelines to help promote the caring and ethical work environment embodied in our
mission statement: We improve the lives we touch through the delivery of high quality
health care and everyday compassion.
To whom does the Code of Conduct apply?
Everyone at Genesis – all covered persons from entry-level to top management. Code of
Conduct training is required within 30 days of hire and then once each year.
Employees certify receipt, review, understanding, and agreement to abide by the Code’s
principles as a condition of continued employment, within specific announced timeframes.
What is important about the Code of Conduct?
As covered persons, we all share a commitment to legal, ethical and professional conduct in
everything we do. We support these commitments in our work each day, whether we care for
patients, order supplies, prepare meals, keep records, pay invoices or make decisions about the
future of the Company. Success as a provider of healthcare services depends on us – our personal
and professional integrity, our responsibility to act in good faith and our obligation to do the
right things for the right reasons.
The principles in the Code of Conduct are not suggestions; they are mandatory standards.
There is no justification for departing from the Code of Conduct, no matter what the situation
may be. Violations of the Code of Conduct or policies and procedures are grounds for dismissal.
The Code of Conduct supplements the Genesis Employee Handbook
and the specific policies and procedures that apply to your job. Of course, no
single resource can answer every question or cover every concern you may
encounter at work.
Let your own good judgment and professional responsibility also guide you.
Seek to avoid even the appearance of improper behavior at work – with your
colleagues, customers, and other business associates.
When in Doubt, Reach Out! Report your concerns. If you have
questions or concerns about the Code of Conduct, or ANY moral, legal or
ethical issue, use the Reporting Process shown on page 3.
Managers, at all levels and divisions of the Company, have the primary responsibility for
communicating – both formally and informally – the paramount importance of compliance
to all employees. They are equally responsible for promoting adherence to the Program.
Informally, managers focus on open communication about integrity. They create an
atmosphere that encourages integrity and that fosters reporting of compliance issues and
non-retaliation. Managers answer questions raised by employees, or obtain answers from a
Compliance Liaison or the Compliance Officer.
OUR STANDARD OF CONDUCT
Genesis is committed to the delivery of quality healthcare services. To achieve
that goal, it is the policy of Genesis to conduct all business affairs with the
highest level of integrity.
Genesis requires that every employee strictly comply with all applicable laws and regulations.
The Genesis Standard of Conduct applies to all aspects of Genesis operations including patient
care, billing, and maintenance of accurate corporate records, business conduct and all other
facets of the Company’s operations.
THE CODE OF CONDUCT EXPANDS ON THE STATEMENTS IN
THE GENESIS STANDARD OF CONDUCT
TABLE OF CONTENTS
TOPIC
Page No.
Our Core Values
1
Our Code of Conduct
2
Reporting Issues of Concern
3
Civil Rights Compliance
6
Professional Standards
9
Care Excellence: Our First Priority
10
Legal Standards
15
Professional Integrity
16
Business Integrity
21
Financial Integrity
27
HIPAA Compliance
30
Information Security
32
Violations of this Code
34
Compliance Resources
36
Code of Conduct Acknowledgment
39
EACH EMPLOYEE IS A VITAL LINK TO ENSURING INTEGRITY
IN HIS OR HER LINE OF BUSINESS
OUR CORE VALUES
Employees, directors, officers and contractors are expected to uphold
the principles of the Genesis Core Values.
THANK YOU FOR COMMITTING TO PROVIDE QUALITY CUSTOMER SERVICE TO EVERYONE
– PATIENTS, RESIDENTS, FAMILIES, BUSINESS ASSOCIATES, INVESTORS, COLLEAGUES
1
OUR CODE OF CONDUCT
The Code of Conduct provides guidelines to help promote the caring and ethical work
environment embodied in our Mission Statement.
We improve the lives we touch through the delivery of
high quality health care and everyday compassion.
The Code of Conduct sets clear expectations and standards. It reinforces individual
integrity and accountability. It promotes compliance with applicable governmental laws, rules
and regulations, as well as internal policies and procedures.
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All covered persons are expected to meet professional standards and exercise good
judgment regarding how best to uphold ethical behavior every day.
A supervisor or member of the Compliance Team is always available to discuss any
issues or to answer questions about this Code of Conduct or the Compliance Program.
Each employee is a vital link to ensuring integrity within his or her line of business.
Thank you for your commitment to provide quality customer service,
not only for our patients, residents, and their families,
but also for business associates, investors, and fellow employees.
EACH EMPLOYEE HAS A RESPONSIBILITY TO MEET ETHICAL, LEGAL,
AND PROFESSIONAL STANDARDS
2
REPORTING ISSUES OF CONCERN
As a covered person, you have a duty to ensure that the Company is doing everything practical to comply
with applicable laws. That’s why it’s important for you to report – right away – any situations you
believe may be unethical, illegal, unprofessional, or wrong. Tell someone immediately if you have a
clinical, ethical or financial concern, or if you suspect a violation of this Code of Conduct. You are
obligated to promptly report. Use this Reporting Process. Also, comply with federal, state, and local
reporting obligations – like the Elder Justice Act. Read page 13 for the specific reporting times you
must meet under the Elder Justice Act.
Reach Out Reporting Process – How to Communicate Compliance Issues
1
2
3
4
First, talk to your supervisor or manager. He or she is most familiar
with the laws, regulations and policies that relate to your work.
3
If you are not comfortable talking with your supervisor or are not satisfied with
the response you receive, talk to another member of the management team,
or someone from human resources.
If you still have a concern, discuss with a regional representative or
Compliance Liaison (see Genesis Central for contact details).
If none of the above steps resolves your questions or concerns, or if you prefer,
call the toll-free Genesis Reach Out Line at (800-893-2094) for assistance. You
may call anonymously.
3
QUESTIONS ABOUT REPORTING ISSUES OF CONCERN
What if I’m not sure if it’s a compliance issue?
Talk about the issue with
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your supervisor
a member of management
a Compliance Liaison
the Compliance Officer
Do I have to give my name when I make a report?
No. You can make or file a report anonymously. Remember though, you must give enough
information to help someone to start an investigation of your concern.
Can I get in trouble for reporting a compliance issue?
No. You may make reports without fear of reprisal, retaliation, or punishment for reporting.
Anyone, including a supervisor, who retaliates against anyone for reporting an issue, will be
disciplined, including possible dismissal.
What if I’m not clear about my duty under the Compliance Program?
Ask any questions you might have about the Compliance and Ethics Program. Ask a
supervisor, management, a Liaison, or the Compliance Officer. All employees are required to
act in accordance with the Program as a condition of employment.
Do I have to report myself if I’m the one who is non-compliant?
Honesty is the best policy. When an employee promptly discloses his or her own noncompliance, this positive action will be considered when the Company is deciding on the
appropriate consequences.
What if I am a witness, or accused of a violation of Company policy or
the law? You will be asked to cooperate in the related investigation. Cooperation
means speaking truthfully and candidly to an internal investigator. You are expected to speak
openly in an interview, and/or a written statement that documents your direct knowledge.
4
REPORTING VIOLATIONS TO OTHER AGENCIES
The Company’s policy is to provide information to all covered persons about the state and
federal fraud laws, including the False Claims Act, remedies available under these provisions
and how covered persons and others can use them, and whistleblower protections available to
anyone who claims a violation of the federal or state false claims act.
The specific policies are described in the Employee Handbook. If you need more information,
you can find it there.
Nothing in this Code prohibits covered persons from reporting possible violations of law or
regulation to any governmental agency or entity, or making other disclosures that are
protected under “whistleblower” provisions of federal or state law or regulation.
Covered persons do not need the prior authorization of the Company to make any such
reports or disclosures, and do not need to notify the Company that such reports or disclosures
have been made.
”Honesty is the cornerstone
of all success, without which confidence and ability to
perform shall cease to exist.”
-- Mary Kay Ash
5
Civil Rights Compliance
NON-DISCRIMINATION
Genesis HealthCare (GHC) does not exclude, deny benefits to, or otherwise discriminate against
any person (i.e., patients, employees, or visitors) on any grounds prohibited by federal, state or
local laws on the basis of race, color, religion, national origin, gender, gender expression, gender
identity, sexual orientation, age, disability, marital status, pregnancy, ancestry, genetic
information, amnesty or veteran status in admission to, participation in, or receipt of the services
and benefits under any of its programs and activities whether carried out by the GHC Center
directly, or through a contractor or any other entity with which the GHC Center arranges to carry
out its programs or activities.
Genesis HealthCare is committed to compliance with civil rights regulations.
WHAT YOU NEED TO KNOW
Federal Law protects qualified individuals from discrimination based on disability, limited
English language proficiency, and many other factors as discussed above.
The non-discrimination requirements of the law apply to employers and organizations that
receive financial assistance from any federal department or agency, including the United States
Department of Health and Human Services.
Regulations specifically forbid organizations and employers from excluding or denying
individuals with disabilities an equal opportunity to receive program benefits and services.
It also defines the rights of individuals with disabilities to participate in, and have access to
program benefits and services.
6
CIVIL RIGHTS COMPLIANCE
Our Commitment
We are committed to providing appropriate auxiliary aids and services in a timely
manner to ensure effective communication and equal opportunity to participate in
activities, programs and services. Genesis’s focus is on equal access to services and
equal opportunity for the disabled.
Genesis recognizes that deaf, hard of hearing, blind, or otherwise disabled patients, and
their companions, need and have a right to appropriate auxiliary aids and services in
order to access and fully participate in the health care we provide.
In addition, Genesis will take reasonable steps to ensure that persons with Limited
English Proficiency (LEP) have meaningful access and an equal opportunity to
participate in the services, activities, programs, and other benefits as provided.
In accordance with the Section 504 prohibition on retaliation, Genesis will not retaliate,
intimidate, threaten, coerce or discriminate against any person who has filed a complaint
or who has assisted or participated in the investigation of any grievance.
As health care providers, it is very important that we communicate effectively to provide
appropriate, effective, quality health care services. We do this to ensure that:
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We understand the patient’s symptoms and pain levels
There is understanding of the problem or diagnosis
We provide the correct treatment
Our patients understand medical instructions, warnings or prescription guidelines
For patients, prior to or within 24 hours of admission, residents are fully assessed so we
understand their capabilities and needs.
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After assessment, we document identified support services/aids in the individual’s care
plan and review the plan on a regular basis
As needed, we update the plan to reflect any revised services/aids
Onsite language interpreter services or sign language interpreter services may be
necessary; we arrange for those services based on the assessed needs of each patient
Disabled patients may be accompanied by service animals; specific conditions apply as
discussed in our policies and procedures
7
CIVIL RIGHTS COMPLIANCE
PROHIBITED DISCRIMINATORY ACTS
The regulatory provisions against discrimination apply to service availability,
accessibility, delivery, employment, and administrative activities and
responsibilities of organizations receiving federal financial assistance.
Genesis locations will not deny:

the opportunity to participate in or benefit from federally funded programs, services or
other benefits to individuals with disabilities and limited English proficiency

access to programs, services, benefits or opportunities as a result of physical barriers

employment opportunities, including hiring, promotion, training, and fringe benefits,
for which individuals with disabilities are otherwise entitled or qualified
Additional information regarding compliance with civil rights regulations can be found on
Genesis Central (at http://central.genesishcc.com/sites/Compliance/Section504/default.aspx), or by
reviewing these regulations:

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Title VI and VII of the Civil Rights Act of 1964
Section 504 of the Rehabilitation Act of 1973
Age Discrimination in Employment Act
Section 1557 of the Patient Protection and Affordable Care Act of 2010, 42 U.S.C. §
18116
The Americans with Disabilities Act
Regulations of the U.S. Department of Health and Human Services, at Title 45 Code of
Federal Regulations Parts 80, 84, and 91
Other applicable federal civil rights statutes
8
PROFESSIONAL STANDARDS
These standards provide a brief summary of key professional expectations. Refer to associated policies and procedures for more
information.
Standard
Behavior
Allegations of Abuse,
Neglect, Misappropriation
or Crime
Statement on Harassment
Accurate Books and
Records
Competition and
Solicitation
Gifts
Licenses/Certifications
Political Contributions
Substance Abuse
Workplace Violence
Rules and Regulations
Disciplinary Procedure
Complaints/Disputes
What it means
Conduct which limits, restricts or interferes with our ability to
respond to our customers’ needs is not acceptable.
The Company will not tolerate any type of patient abuse or neglect.
Covered persons must immediately report any incident of suspected
or known abuse, neglect, misappropriation or crime against a
patient.
Effective working relationships must be based on mutual respect.
Harassment is unacceptable.
All books and records must be accurate, complete, and truthful,
including those maintained for financial reporting, health care, and
other business purposes. Documentation in all records must comply
with regulatory and legal requirements and support business
practices and actions. No one may falsify or tamper with any
information in any record.
Certain employees must not compete with or solicit clients or
business away from Genesis, or influence employees to leave
Genesis.
Covered persons must not accept or offer any form of gifts,
gratuities, tips and/or loans from patients, their family members,
suppliers, vendors, customers, or companies seeking to do business
with Genesis.
All covered persons who need licenses or certifications must
maintain credentials in compliance with state and federal laws.
Payments of Company funds and/or use of the Company’s name in
support of political causes may be made only if permitted under
applicable law and approved in accordance with Company policy.
The distribution, possession or illegal use of a controlled substance
in the workplace is prohibited.
Fighting, disorderly conduct, physical, verbal or mental abuse of any
person is unacceptable.
All covered persons must comply with the industry regulations and
Company policies and procedures.
Genesis supports a progressive discipline policy.
Give notice of complaint to supervisor, then to next level up and so
on, or to the Reach Out Line (800.893.2094).
CARE EXCELLENCE: OUR FIRST PRIORITY
Our most important job is providing quality care to our patients. This means offering
compassionate support to our patients and their families. It means working toward the best
possible outcomes, while following all healthcare rules and regulations.
We care for people who are especially vulnerable. They may have impaired or limited cognitive
abilities. They might have physical restrictions because of illness, injury or disease.
It is our responsibility to respect, protect and care for every patient and resident
with compassion and skill.
PROVIDING QUALITY CARE
Our primary commitment is to provide the care, services, and products our patients need to reach or
maintain their highest possible levels of physical, mental, and psychosocial well-being. Our policies and
procedures guide us toward the achievement of this goal.
To meet quality of care standards, we do the following…
° Develop interdisciplinary plans of care for all patients
° Review goals and plans of care to ensure our patients’ ongoing needs are being met
° Provide only medically necessary, physician-prescribed services and products to meet patients’ clinical needs
° Confirm that services, products, medications are within accepted standards of practice for the patient’s
medical condition
° Provide and accurately document services and products that are reasonable in frequency, amount, and duration
° Measure clinical outcomes and patient satisfaction to confirm quality care goals are met
° Provide accurate and timely documentation and record keeping
° Ensure patient care is given only by providers with the appropriate background, experience and expertise
10
CARE EXCELLENCE: OUR FIRST PRIORITY
Patients receiving healthcare services have clearly defined federal and state rights
To honor these rights, we must:
• Provide the same quality care to everyone regardless of race, color, national origin, disability,
gender, or age
• Treat all patients with compassion, courtesy, professionalism and respect
• Protect every patient from physical, emotional, verbal or sexual abuse or neglect
• Protect all aspects of patient privacy and confidentiality
• Obtain permission from patients or their authorized representatives before releasing
personal, financial, or medical information to anyone outside of the Company verbally, or via
paper or electronic media
• Limit access to medical and other records only to employees, physicians or other healthcare
professionals who need the information to do their jobs
• Respect patient's personal property and money and protect it from loss, theft, improper use
and damage
• Respect the right of patients and their authorized representatives to participate in decisions
about their care
• Respect the right of patients and/or their authorized representatives to access their medical
records upon request
• Recognize that patients have the right to consent to or refuse care
• Protect the patient's right to be free from physical and chemical restraints
MEET PROFESSIONAL STANDARDS AND EXERCISE GOOD JUDGMENT.
UPHOLD ETHICAL BEHAVIOR EVERY DAY.
11
CARE EXCELLENCE: OUR FIRST PRIORITY
Any employee who abuses, neglects or commits a crime against a patient may be dismissed.
In addition, legal or criminal action may be taken. If you ever observe any incident of suspected
or known abuse, neglect, misappropriation, or crime against a patient, you must immediately
report it using the Reporting Process (see page 3). You must also report to outside agencies if
required. If you do not know if reporting to an outside agency is required, please discuss the
situation further with your supervisor.
Prompt reporting is important to ensure patient safety. Failure to report immediately may be
considered gross misconduct and grounds for termination of employment.
ABUSE AND NEGLECT – ZERO TOLERANCE
The Company will not tolerate any type of patient abuse or neglect – physical, psychological,
emotional, verbal or sexual. Patients must be protected not only from employees, but also from
other patients, volunteers, agency staff, family members, legal guardians, friends, or any other
person. The standard is for all patients at all times.
Abuse
Sexual Abuse
• Any physical contact
with a patient that is
harmful or punitive,
regardless of injury or
pain
• Psychological abuse
(sometimes called
emotional, verbal, or
mental abuse) is
mistreating someone
using words or
deception or causing
mental or emotional
fear or anguish
•For example,
emotional or
psychological abuse
can be name-calling,
insulting, teasing,
yelling, threatening,
belittling, or lying
•Any type of
inappropriate
physical contact with
a patient
• Sexual harassment
• Sexual coercion
• Sexual assault
Neglect
• Failure to provide
goods or services
necessary to avoid
physical harm,
mental anguish, or
mental illness
• Any situation that
can be considered
neglect is llegal and
will not be tolerated
Misappropriation
Criminal Activity
• Deliberate
misplacement,
exploitation, or
wrongful temporary
or permanent use of
a resident's personal
belongings or money
without the resident's
consent
• There is no
miniumum value
associated with
misappropriation
•Any action that may
constitute a crime
committeed against a
patient, whether by
an employee or any
other individual
12
ELDER JUSTICE ACT
Within the Affordable Care Act of 2010, the Elder Justice Act requires that
covered persons in federally funded long-term care facilities report all
reasonable suspicion of crimes.
 Crimes including serious bodily injury must be reported immediately and not later than two
hours after you suspect something. All other reports must be made within 24 hours of your
suspicion
 Reports must be made to the state survey agency and local law enforcement
 Administrators and Directors of Nursing can assist in reporting
Failure to report may result in fines and penalties, as well as disciplinary action
including termination of employment/services.
When in doubt, report your concerns. Report what you
see as soon as possible!
If you have questions or concerns about the Code of Conduct,
the Elder Justice Act, or ANY moral, legal or ethical issue, use the
Reporting Process outlined in this booklet on page 3.
13
PATIENT CONFIDENTIALITY & PROPERTY
Federal law protects the confidentiality of patients’ medical, financial and
personal information.
Patient information is exchanged in verbal, written and electronic forms. HIPAA regulations
require that we protect patient information from being seen, heard, or read by anyone who is not
authorized to do so.
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Only specified individuals are permitted to access patient records: the patient, or his or her
authorized representative, the individual’s physician and the staff members who need the
information
No medical, financial, or personal information about a patient may be disclosed to anyone
else, in any form, without permission from the individual or his/her authorized representative
The right to privacy means that we cannot answer questions from friends,
relatives or the news media without written authorization.

All inquiries from reporters must be referred to your supervisor
PATIENT PROPERTY
Covered persons must respect patients’ personal property and protect it from loss, theft, damage
or misuse. Covered persons who have access to property or funds, including resident trust funds,
must maintain accurate records and accounts and ensure that these funds are properly
safeguarded.
CONFIDENTIALITY IS MORE THAN A COURTESY…
IT’S THE LAW!
14
LEGAL STANDARDS
These standards provide a brief summary of key legal/regulatory requirements. Please refer to associated policies and
procedures for more information.
Standard
What it means
Medical Necessity
The Company will bill only for services which are warranted by a patient’s
current and documented medical condition, and which are ordered by a
physician.
Billing for Services
Rendered
The Company will bill only for medically necessary services that are actually
rendered. Bills and claims for services should be reviewed for accuracy prior
to submission. Any post-submission discovery of errors should be reported
via the Reporting Process, with corrections submitted promptly.
False Claims
The Company will not make false statements on medical claim forms to
obtain payment, or higher payment, to which it is not entitled.
Anti-Kickbacks
Patients are accepted based solely on clinical needs and our ability to
deliver the services that patients need. Patients are referred to other care
providers the same way: based solely on each patient’s individual care
needs and the ability of the providers to meet those needs. We never accept
or offer anything of value in exchange for patient referrals, or submit
claims for payment for patients who were referred inappropriately.
The Company will submit cost reports that accurately reflect actual
allowable operating costs.
Cost Reports
Billing Codes
The Company will use billing codes that actually reflect the service
furnished and which provide for the appropriate payment rate.
Bundling of Services
The Company will bill for tests or procedures that are required to be billed
together as a single bill and not in a piecemeal or fragmented fashion.
Licensing
The Company will bill only for services that are rendered by a licensed
practitioner.
Covered Services
The Company will not bill for non-covered services as covered ones.
Carriers
The Company will not bill the wrong carrier to receive higher
reimbursement.
Physician Self-Referral
The Company will not permit physicians to make referrals to an entity in
which the physician or an immediate family member has a financial
interest.
Retention of Records
The Company will maintain all medical documentation required by federal
and/or state law and internal policies. Records will only be destroyed in
accordance with Company policy.
15
PROFESSIONAL INTEGRITY
Confidential Information
You must not disclose Company confidential or proprietary information. Some examples of
confidential or proprietary information within the meaning of this policy are:
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Company trade secrets;
Information that is subject to strict federal financial disclosure laws such as pending
dividend changes, earnings estimates, mergers or acquisitions or other sensitive
information that impacts our shareholders;
Non-public information about the Company’s operating results, and financial performance,
contract terms or arrangements, all of which could be used by competitors to the
Company’s disadvantage;
Confidential or personal information about patients to which you have access as a result of
your employment with the Company that could, if disclosed inappropriately, subject the
Company or you to liability;
Private information about the Company’s employees and vendors which, if disclosed, could
violate privacy laws or result in legal actions against the Company.
You may not disclose any such information to any unauthorized person or entity unless
specifically directed or permitted by an appropriate Company official to do so. Any questions or
requests for such information that you receive must be directed to your supervisor.
Any employee who violates this policy will be subject to disciplinary action, up to and including
termination.
Covered persons must also consider the Insider Trading and Health Insurance Portability
and Accountability Act sections of the Code of Conduct when determining whether confidential
information may be shared.
RESPONSIBLE USE OF ALL CONFIDENTIAL INFORMATION IS
CRITICAL TO MAINTAIN ITS CONFIDENTIAL NATURE.
16
PROFESSIONAL INTEGRITY
COVERED PERSONS MUST REPORT ACTUAL OR POTENTIAL CONFLICTS
OF INTEREST. USE THE REPORTING PROCESS ON PAGE 3.
Conflicts of interest in the workplace can pose a
potential for harm to the company’s business interests, or create
an appearance of improper influence.
A conflict of interest exists when a person’s private interests
interfere, or appear to interfere, in any way with the interests of
the company.
Conflicts of interest also arise when a covered person or a
member of his or her immediate family receives improper
personal benefits as a result of his or her position in the
company.

Covered persons cannot employ or engage family members
in company positions that create conflicts of interest.
o
Examples include, but are not limited to, an employee:
having direct supervisory authority over a family
member; having payroll responsibility over a family
member; or having significant influence over the pay,
benefits, career progression or performance of a family
member without the express permission of the engaging
employee’s supervisor.
No covered person may personally gain from any purchase or
business decision in which that person participated on behalf of
the company.
Covered persons
must avoid situations
that create,
or appear to create,
conflicts that may
make it difficult
for the person
to perform work, or
make decisions
objectively
and effectively
NO COVERED PERSON
SHOULD ENGAGE IN
UNDISCLOSED OR
UNAPPROVED BUSINESS
ARRANGEMENTS ON
BEHALF OF THE
COMPANY WITH FAMILY
MEMBERS
Each full-time employee is expected to serve the Company’s interests on a full-time basis.
Each employee should disclose, to his/her supervisor, any other employment for an employer
who is in the same business as the Company. An officer or member of management will
determine if the other employment relationship constitutes a conflict of interest.

The continuation of the same facts and circumstances occurring in the ordinary course of
business, as well as interests arising out of those circumstances, will not constitute a conflict of
interest, if they have been disclosed to, and approved by, the Company’s Board of Directors as of
the date of the Directors’ adoption of this Code
17
PROFESSIONAL INTEGRITY
CARE TO RELATIVES
You must tell your supervisor if you are providing direct care or supervising the
care of one of your relatives, or doing the same for anyone for whom you have
power of attorney or guardianship.
When you tell your supervisor, the situation will be evaluated to decide if there is a
conflict of interest and what is in the best interest of the relative, patient, or
resident.
Every situation will be addressed on a case-by-case basis.
18
PROFESSIONAL INTEGRITY
INELIGIBLE PERSONS
You are obligated to immediately notify your supervisor
and the Compliance Officer of any communication to you
from an outside party about your inability to provide services
that are reimbursed by Medicare or Medicaid.
The Compliance Department routinely searches the
Department of Health and Human Services' Office of Inspector General list of excluded individuals/
entities, the Systems for Award Management exclusions list, and similar state exclusions lists, to ensure
that excluded individuals are not employed or contracted with the Company.
Why does the Compliance Department do that routine search?
Federal Law prohibits a company from contracting with, employing, or billing for services
provided by an individual or entity that
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is excluded, or ineligible to participate in, federal healthcare programs
is suspended or debarred from federal government contracts
has been convicted of a criminal offense related to the provision of healthcare items or services and
has not been reinstated in a federal healthcare program after a period of exclusion, suspension,
debarment, or ineligibility
BACKGROUND SCREENING
All job offers for new employees, or eligible former employees applying for rehire, are
contingent upon successful completion of a comprehensive background check, including review
of eligibility described above.

Transferring employees may also be subject to background screening when the transfer
involves a promotion or change in the state of employment or by law.
This policy protects the patients and residents we serve, ensuring they are safe and secure
in our care.
DRUG AND ALCOHOL
TESTING
Our ability to provide quality care can be dangerously affected by
drug and alcohol abuse. Genesis requires all new employees to
undergo a drug test as a condition of employment.

Under certain circumstances, existing employees are also subject
to drug/alcohol testing.
19
PROFESSIONAL INTEGRITY
You must notify your Division Human Resources Manager or Director if you are arrested,
indicted, or convicted of a misdemeanor or felony, or have pleaded guilty or no contest.

You may also notify Genesis by contacting the HR Service Center Line at 888-HR
AT GHC (888-472-8442). Choose the option for “Employee Relations Concerns.”
ARREST INDICTMENT OR CONVICTION
What will happen when I notify Genesis of my arrest, indictment or conviction?
Management, in conjunction with Human Resources, will review all available information before
taking any action.
If you are convicted of certain serious crimes, or fail to report this activity, you will not be
permitted to continue employment.
What else do I need to know?
 In the event of a conflict between this policy and applicable state law, the applicable state
law will apply.
 If you have information of a co-worker’s arrest, indictment or conviction, report this
information. Use the Reporting Process described on page 3 in this manual.
LICENSURE AND CERTIFICATION
If your position requires that you be licensed, certified and/or registered, you must provide
evidence of certification before starting employment.

During your employment with us, it is your responsibility to renew your license as
required by law, provide verification to your supervisor, and notify all appropriate
agencies if your name or address changes.

You are also required to report to your supervisors if any licensing agency has initiated
an investigation, action has been taken against your license or certification, or if you have
worked when your required license/certification has expired or lapsed.
20
BUSINESS INTEGRITY
BUSINESS OPPORTUNITIES
All covered persons have an obligation to advance the Company’s interests when the
opportunity to do so arises.
If an executive officer or director of the Company wishes to pursue a business opportunity - that
is in the Company’s line of business and was discovered or presented through the use of
corporate property or information, or because of his or her position with the Company - he or she
must first fully present the business opportunity to the Company’s Board of Directors.

If the Company’s Board of Directors elects not to pursue the business opportunity, then
the executive officer or director may pursue the business opportunity in his or her
individual capacity on the same terms and conditions as originally proposed and
consistent with the other ethical guidelines set forth in this Code.
All other covered persons who wish to pursue a business opportunity - that was discovered or
presented through the use of corporate property, information, or because of the employee’s
position with the Company - must first fully disclose the terms and conditions of the business
opportunity to the employee’s immediate manager. The immediate manager will contact the
General Counsel and the appropriate management personnel to determine whether the Company
wishes to pursue the business opportunity. If the Company waives its right to pursue the
business opportunity, the employee may pursue the business opportunity in his or her individual
capacity on the same terms and conditions as originally proposed and consistent with the other
ethical guidelines set forth in this Code.
PROPER USE OF RESOURCES AND ASSETS
Business assets (meaning supplies, equipment or offices) must be used in a
responsible manner and for legitimate business purposes. A business asset should not
be used for personal purposes without the prior approval of a supervisor. The occasional personal
use of telephones and copying machines, where the costs are insignificant, are permitted.
However, any use of business assets for personal financial gain is strictly prohibited. Use of any
business asset for any charitable or political purpose must be in accordance with Company
policy. In addition, use of Company e-mail must be in accordance with Company policy.
NO EMPLOYEE MAY USE CORPORATE PROPERTY, INFORMATION, OR HIS OR HER POSITON WITH
THE COMPANY, FOR PERSONAL GAIN; NOR SHOULD EMPLOYEES COMPETE WITH THE COMPANY.
21
BUSINESS INTEGRITY
FAIR DEALING
All covered persons are expected to compete vigorously
in business dealings on behalf of the company, but, in
doing so, must deal fairly with other covered persons and
the company’s investors, service providers, suppliers, and
competitors.

Covered persons must not take unfair advantage
through manipulation, concealment, abuse of
privileged information, misrepresentation of material
facts, or any other unfair dealing practice

Covered persons must never seek to induce another
party to breach a contract in order to enter into a
transaction with the company
PURCHASE
DECISIONS SHOULD
BE MADE ONLY ON
SOUND BUSINESS
PRINCIPLES AND IN
ACCORDANCE WITH
ETHICAL BUSINESS
PRACTICES
BUSINESS ARRANGEMENTS
The company has pre-approved purchasing arrangements with many vendors, suppliers, and
service providers to ensure quality cost-effective services. Proposals for items or services to
be obtained outside these arrangements must comply with guidelines for approval authority,
documentation, and pre-approval. Any questions or concerns should be discussed with the
Law Department.
The company has developed standard form agreements appropriate to document most
business arrangements. These forms can be obtained from the Law Department.
Proposals for modification to a form agreement or utilization of a non-form agreement must
receive advance approval from the Law Department.
ANTITRUST LAWS
Business activities must be conducted in accordance with applicable antitrust and
competition laws. Some of the most serious antitrust offenses are agreements between
competitors that limit independent judgment and restrain trade. Examples include agreements to
fix rates, or to divide a market for customers, territories, products or purchases. Any
communication with a competitor's representative, no matter how innocent it may seem at the
time, may later be subject to legal scrutiny and form the basis for accusations of improper or
illegal conduct. All covered persons should avoid situations from which an unlawful agreement
could be inferred.
22
BUSINESS INTEGRITY
KICKBACKS AND REFERRALS
A “kickback” is a receipt of anything of value, including cash, goods, supplies, services, or
other remuneration, in exchange for referring business reimbursable under federal or state, or
certain private, reimbursement programs.
All agreements with referral sources and agreements where the company is the referral source
must be in writing; and, if a format to be utilized has not been pre-approved by the Law
Department, it must be submitted for review and approval before the agreement is finalized.
ACCEPTING OR OFFERING KICKBACKS
IN EXCHANGE FOR REFERRALS IS AGAINST THE LAW
AND IS NOT TOLERATED
PHYSICIAN, HOSPITAL, HEALTH CARE
PROVIDER/SUPPLIER ARRANGEMENTS
Federal and state laws and regulations
govern the relationship among skilled
nursing facilities, physicians, other health
care facilities, and ancillary health care
providers. Covered persons who negotiate
contracts or other transactions, file claims
for payment, or make payment for services
rendered, must be aware of the laws,
regulations, and policies that address
relationships between these health care
providers/entities. Proposed transaction
structures must comply with applicable
legal requirements imposed by federal/state
laws, and receive advance approval from
the Law Department.
Once implemented, transactions must be
conducted consistent with the approved
structure to maintain compliance with legal
requirements.
INTELLECTUAL PROPERTY RIGHTS
The Company’s intellectual property
includes all registered service marks, i.e.,
trademarks, trade names, logos, etc..
Respect all copyright and other intellectual
property laws.
For the Company’s
protection as well as your own, it is critical
that you show proper respect for the laws
governing copyright, fair use of copyrighted
material owned by others, trademarks and
other intellectual property, including the
Company’s own copyrights, trademarks and
brands. The Company licenses the use of
much of its computer software from outside
companies. In most instances, this computer
software is protected by copyright.
Unauthorized copies of computer software
must not be made, used or acquired.
23
BUSINESS INTEGRITY
GOVERNMENTAL INVESTIGATIONS AND LITIGATION
Obeying the law, in both letter and spirit,
is the foundation on which the company’s
ethical standards is built
You must respect and obey the laws of the cities, states, and country in which the Company
operates. If a law ever conflicts with a policy in this Code, you must comply with the law.
When you have doubts about the application of a standard, or
where this Code does not address a situation that presents any
ethical issue, seek guidance using the Reporting Process on
page 3.
It is Company policy to cooperate with government investigations. Government investigations
are part of the healthcare environment today. The procedures for cooperating with these
investigations can be complicated. The Company has specific policies and procedures that
provide more detailed information on how to respond in such situations.
WHEN IN DOUBT, REACH OUT! If you are contacted about investigations related to the
company or your employment, we recommend that you ask your supervisor for guidance (see
Reporting Process p.3).
Supervisors must obtain guidance from the Law Department. The Law Department can verify
the investigator’s credentials, determine whether or not the contact is legitimate, and help
make sure the proper procedures are followed for cooperating with the investigation.
If someone who claims to be an investigator or inspector contacts you at work, you can seek
advice from your supervisor prior to responding.
In some cases, government investigators or inspectors, or people presenting themselves as such,
may contact you outside the workplace.


You have a legal right to contact an attorney before you respond to an investigator's
questions.
Contacting an attorney or your supervisor before talking with an investigator does not in
any way suggest improper conduct.
24
BUSINESS INTEGRITY
DIRECT YOUR QUESTIONS
REGARDING THE RESPONSIVENESS OF A RECORD TO SUBPOENA,
OR ITS PERTINENCE TO AN INVESTIGATION OR LITIGATION, OR
THE APPROPRIATE PRESERVATION OF CERTAIN RECORDS,
TO THE LAW DEPARTMENT
If you receive a subpoena or other written request for information (such as a civil
investigation demand) from the government or a court, you may contact your supervisor before
responding. Contacting your supervisor is not required.

Supervisors are required to contact the Law Department for advice in these matters.
In complying fully with these policies, you must NEVER lie or make false or misleading
statements to any government investigator or inspector.
In complying fully with these policies, you must NEVER destroy or alter any records or
documents in anticipation of a request from the government or court.
In complying fully with these policies, you must NEVER attempt to persuade any person to
give false or misleading information to a government investigator or inspector.
In complying fully with these policies, you must NEVER be uncooperative with a government
investigation.
As may be directed by the Law Department, covered persons must retain and preserve all records
(documents, e-mails, electronic data, voicemails, etc.) in their possession or control that may be
responsive to the subpoena, or are relevant to the litigation, or that may pertain to the
investigation. Once a directive is issued to retain records, covered persons must not destroy
relevant records and must stop the destruction cycle of records subject to automatic destruction
pursuant to record retention policies.
25
BUSINESS INTEGRITY
Laws of some jurisdictions require
registration and reporting
by anyone who engages in
such a lobbying activity as contacting
government officials to obtain or retain business.
Failure to register can lead to a ban on business
as well as other civil or criminal penalties.
Individuals who do not normally participate in lobbying activities, in performance of agreed
upon job duties with Genesis, should contact the Government Relations Department for
guidance in these efforts.
The company is committed to
fair competition among vendors and
contractors with whom we may do
business.
Arrangements between the company
and its vendors must always be
approved by management.
Contractors or vendors, who provide patient care, reimbursement, or other services to
beneficiaries of federal healthcare programs, are subject to the Compliance Program, and must:




maintain our standards for the products and services they provide to our Company and patients
comply with all policies and procedures as well as the laws and regulations that apply to their business or
profession - including the Federal False Claims Act and similar state laws and federal and state laws
governing confidentiality of resident and employee personal information
maintain all applicable licenses and certifications, and have available current documentation of that
information
require that their employees comply with this Code of Conduct, the Compliance Program, and training as
appropriate
The Company encourages vendors to adopt their own comparable ethical standards in their business
agreements for healthcare services. Business Associate Agreements must be obtained in writing and approved
by the Law Department prior to the provision of services to residents. Contact the Law Department for more
information about business arrangements.
MARKETING AND ADVERTISING: The Company uses marketing and advertising activities
to educate the public, increase awareness of our services, and recruit new employees.
Promotional materials and announcements (whether verbal, printed, or electronic/Internet) will
present only truthful, informative, non-deceptive information. Individual resident information
will not be used for marketing without appropriate authorization.
26
FINANCIAL INTEGRITY
FINANCIAL REPORTS & ACCOUNTING RECORDS
The company promotes fair, full, accurate, timely, and
understandable disclosures in all public communications.
This includes reports and documents that are filed with, or
submitted to, governmental authorities.
Covered persons, involved in creating, processing, or
recording financial reports and accounting records, are
responsible for the integrity of the information. They must
make sure that all information is accurate and complete.
Such covered persons shall not create, nor submit, false
claims, false invoices or expense reports, or forged or
altered checks; nor shall they participate in the
misdirection of payments, unauthorized handling or
reporting of transactions, creation or manipulation of
financial information so as to artificially inflate or depress
financial results, or any improper or fraudulent
interference with, or coercion, manipulation or misleading
of, the company’s auditors or the Audit Committee of its
Board of Directors.
Any covered person who observes or suspects any such
activity must immediately report the concern to a
supervisor and to the Reach Out Line, in accordance with
the Reporting Process (page 3). Involvement in or failure
to report such activities will result in disciplinary action up
to and including termination, and, as may be applicable,
referred to authorities for possible prosecution.
AUDIT PROCESSES
No covered person, or agent acting
under the direction of such, shall
directly or indirectly take any action
to coerce, manipulate, mislead, or
fraudulently influence any
independent public, or certified
public accountant engaged in the
performance of an audit or review
of the financial statements of the
company, if that person knows or
should know that such action, if
successful, could result in rendering
the company’s financial statements
misleading.
DISCLOSURE PROCEDURES
Any person designated to make
disclosures must be aware of, and
act in compliance with, company
procedures for developing and
making public disclosure in order to
prevent making inadvertent or
selective disclosure to analysts or
others.
27
FINANCIAL INTEGRITY
Securities Fraud
No employee may knowingly execute, or attempt to execute, a scheme or artifice to defraud any
person in connection with any security of the Company in order to obtain, by means of false or
fraudulent pretenses, representations, or promises, any money or property in connection with the
purchase or sale of any security of the Company.
Insider Trading
Genesis HealthCare, Inc. is a publicly-traded Company, which means that stock may be bought
and sold through the stock market. The law prohibits a person from buying or selling securities
of a public Company at a time when that person is in possession of "material nonpublic
information." This conduct is known as "insider trading.” Passing such information on to
someone who may buy or sell securities (known as "tipping") is also illegal.

Information is "material" if (a) there is a substantial likelihood that a reasonable
investor would find the information "important" in determining whether to trade
in a security; or (b) the information, if made public, likely would affect the market
price of a Company's securities.
Do not disclose material nonpublic information to anyone, including co-workers, unless
specifically authorized to do so in accordance with the Company’s insider trading policy. If there
is any question as to whether information regarding the Company or another Company with
which it has dealings is material or has been adequately disclosed to the public, contact the Law
Department.
28
FINANCIAL INTEGRITY
LOANS
The company does not extend loans/credit to
directors and officers, or covered persons.
Temporary travel advances are not considered loans,
and are permissible. However, permanent travel
advance arrangements are considered loans and are
not permitted.
PAYMENTS TO GOVERNMENT PERSONNEL
The U.S. Foreign Corrupt Practices Act prohibits giving anything of value, directly or
indirectly, to officials of foreign governments, or foreign political candidates, to obtain or
retain business. Illegal payments to government officials of any country are strictly
prohibited.
In addition, federal laws and regulations guide business gratuities that U.S. government
personnel may accept. The promise, offer or delivery to an official or employee of the U.S.
government of a gift, favor or other gratuity, in violation of these rules, would not only
violate company policy, but could also be a criminal offense. State and local governments,
as well as foreign governments, may have similar rules.
All employees, officers and directors are prohibited from offering any form of bribe or
inducement to any person.
ALL EMPLOYEES, OFFICERS, AND DIRECTORS ARE PROHIBITED FROM OFFERING ANY
FORM OF BRIBE OR INDUCEMENT TO ANY PERSON
Health Insurance Portability and Accountability Act
HIPAA STANDARDS
The Company's intent is to comply with all aspects of the HIPAA Privacy and Security
Rules, in policy and in practice.
All covered persons with access to Protected Health Information (“PHI”) must
assure that resident/patient information is maintained in compliance with the
Health Insurance Portability and Accountability Act (“HIPAA”) Privacy and
Security Rules.
Only persons authorized by law may access residents’/patients’ medical records
and other PHI.
The HIPAA Security Rule applies to maintaining electronic information and
communication secure and encrypted.
All information and communication in electronic format must remain secured and
encrypted; and must not be stored outside of the Company’s direct control,
including but not limited to unencrypted storage devices (such as flash drives and
removable disks), home computers or personal e-mail accounts.
UNAUTHORIZED DISCLOSURE OF PHI OR OTHER HIPAA VIOLATIONS MUST BE
REPORTED TO THE REACH OUT LINE
30
Health Insurance Portability and Accountability Act
The Law
The Health Insurance Portability and Accountability Act (HIPAA) and the HiTech Act are
federal laws, which require health care providers to protect the privacy of the patients and
residents we serve. In that effort, we are required to safeguard their electronic protected
health care information (EPHI).
Policy
All covered persons must comply with Company policies and Federal HIPAA rules and
regulations.
Training
Each GHC employee must attend HIPAA training as part of orientation and annual
compliance training.
Privacy
Officer
Any violation of a patient’s or resident’s privacy should be immediately reported to
a supervisor and/or privacy officer designee. The privacy officer designees include:



Center Administrators/Compliance Liaisons
Other freestanding site managers
GHC Compliance Officer
Release of
Information
Disclosure of patient or resident PHI and/or photograph will only be allowed with a
properly completed and signed authorization. Refer to the Corporate Policies regarding
health information management for information.
Authorized
Parties
Only authorized parties should access patient and resident PHI.
Authorized parties include:
Operational
Safeguards



Patient or resident PHI must always be protected from unauthorized parties.






Technical
Safeguards
The patient or resident
A health care provider treating the patient
An authorized family member of the patient or resident
Discuss a resident’s care only with authorized parties and always in a protected area
Discard PHI utilizing a secure HIPAA bin, or shred each document
Retain, secure, and destroy records in accordance with Corporate Policy 4.13, Retention and
destruction of Records Containing Protected Health Information (PHI)
Fax PHI only to a pre-programmed designation or verify the fax number before transmission
Secure PHI when transporting and never leave it unattended
Never remove PHI from the business location without authorization
Patient or Resident EPHI must always be protected.
 Never share your computer password with anyone
 Always use secure/strong passwords
 Log off or lock your computer when left un-attended
 Encrypt electronic mail containing EPHI sent to an external location
 Keep laptop computers in a secure location
 Never use unauthorized storage devices such as unencrypted USBs or external hard drives
Unauthorized Patient and Company information must never be used for personal reasons.
 Never take or use a patient/resident photograph without authorization
Usage


The discussion of confidential Company and patient information on external websites is
not permitted
The sharing of patient/resident information on social network websites is unacceptable
at any time
31
INFORMATION SECURITY
Limited, occasional, or incidental use of electronic
media and equipment for personal purposes is
permitted.
Electronic media, equipment
and services are provided by
the company primarily for
business use.
However, you are not permitted to use the
Internet for improper or unlawful activity–
including visiting pornographic or gambling sites –
or to download or play games on company
computers during scheduled work hours and when
connected to the company network.
Internet use can be tracked. The company can
monitor Internet usage.
Such tracking may include routine audits of email, Internetbased chat rooms, blogs, video-sharing web sites or social
networking web sites for unauthorized disclosure of
confidential information related to patients, or other
employees, or for revealing proprietary business
information.
Email is for business purposes and should be
professional and objective. Email is for business
purposes and should be professional and objective. No
harassing, threatening, intimidating or coercive messages
may be sent by email. Some limited personal use during
non-working time is permitted, but any such
communications may not include large file attachments or
audio/video clips.
THINK BEFORE YOU SEND THAT EMAIL MESSAGE!
SOMETIMES IT’S BEST TO TALK TO OR CALL THE PERSON YOU WANT TO COMMUNICATE WITH
32
INFORMATION SECURITY
Unauthorized disclosure of patient, employee or certain Company information on Internetbased chat rooms, blogs or social networking web sites (such as Facebook), and in email and text
messages sent outside the Company, may violate HIPAA privacy protections, patient rights
and Company policies prohibiting the release of proprietary and internal information.
Such electronic communications often occur under the cover of an on-line alias and they may be
accessed by the public. Online aliases should never be used to discuss any confidential
information, whether related to patients, other employees, or proprietary business information.
User IDs and passwords are provided to access, as
well as to secure and protect, electronic information
from inappropriate disclosure. They create electronic
signatures and track data entries.


User IDs and passwords must be kept confidential
Sharing login or access information is strictly
prohibited
Covered persons are responsible for ensuring that electronic information is protected.
COVERED PERSONS ARE RESPONSIBLE TO KEEP INFORMATION SECURE. SUBSTANTIATED INSTANCES
OF USER ID/PASSWORD-SHARING AND ABUSE OF INTERNET ACCESS ARE GROUNDS FOR DISMISSAL.
33
It is Company policy that any employee who violates this Code will be subject
to appropriate discipline, including possible termination of employment.
Who is responsible for enforcing violations of this Code?
The Board of Directors is ultimately responsible for enforcing violations of this Code by
officers and directors. The Chief Executive Officer is ultimately responsible for enforcing
violations of this Code by all other employees.
How is it determined that a violation has occurred?
The determination will be based upon the facts and circumstances of each particular situation.
If an employee should be thought to have violated the code, what happens
next?
The employee will be given an opportunity to present his or her version of the events at issue
prior to any determination of appropriate discipline.
What are the penalties for violations of this Code?
Appropriate disciplinary penalties may include counseling, reprimands, warnings, suspension
with or without pay, demotions, salary reductions, dismissals, and restitution.
EVERYONE MUST COOPERATE IN INTERNAL OR EXTERNAL INVESTIGATIONS OF MISCONDUCT
AND MAINTAIN THE CONFIDENTIALITY OF ANY INVESTIGATION AND RELATED DOCUMENTS
34
VIOLATIONS OF THIS CODE
Covered persons who violate governmental laws, rules or regulations, or this
Code may also expose themselves to substantial civil damages, criminal fines,
and prison terms.
The Company may also face substantial fines and penalties.
The Company may incur damage to its reputation and standing in the community. Any person’s
conduct, as a representative of the Company, if it does not comply with governmental laws, rules
or regulations or with this Code, can result in serious consequences for both the person and the
Company and/or its subsidiaries.
Everyone must cooperate in internal or external investigations of misconduct. Everyone
must maintain the confidentiality of any investigation and related documentation.
Knowingly making false accusations of misconduct, or failing to cooperate with an internal
investigation will subject any covered person to disciplinary action.
All questions and reports of known or suspected violations of the law or this
Code will be treated with sensitivity and discretion.
An officer, the immediate manager, the Chief Compliance Officer, and the Company will protect
a reporting person’s confidentiality to the extent possible consistent with the law and the
Company’s need to investigate any reported concern.
Any reprisal or retaliation against a person because he or she, in good faith, sought help or filed a
report will be subject to disciplinary action, including potential termination of employment or
removal from office.
THE COMPANY STRICTLY PROHIBITS RETALIATION AGAINST ANY PERSON WHO, IN GOOD FAITH,
SEEKS HELP OR REPORTS KNOWN OR SUSPECTED VIOLATIONS
35
COMPLIANCE RESOURCES
The Compliance Team
Each affiliated company has a team that takes care of compliance
activities.
Team members include Compliance Liaisons, or contacts, who
implement and monitor compliance activities.
Compliance
Department




Compliance
Officer


Compliance
Liaisons





Oversees the Compliance Program
Coordinates and communicates the design, implementation and
monitoring of the Compliance Program
Works with the management of each business line to adopt and
ensure adherence to the policies, procedures, and laws that govern its
business activities
Administers and oversees the Compliance Program for all business
lines
Answers questions, initiates internal investigations when necessary,
and resolves problem
o Call 800-893-2094 to reach the Compliance Officer with any
questions, complaints, concerns, or suggestions regarding
the Program
With the agreement of the Chief Executive Officer, may use any of the
Company’s resources, including any outside consultants considered
useful or necessary, to evaluate and resolve compliance issues and
ensure the overall effectiveness of the Compliance Program
Ensure the Compliance Program is implemented and followed
Ensure all covered persons have direct and immediate resources for
reporting and resolving compliance issues
Available to address questions, complaints, concerns, or suggestions
regarding the Program
Attempt to resolve any compliance issues brought to their attention
Must report all significant compliance issues to the Compliance Officer
and assist in their resolution in any necessary way
36
COMPLIANCE RESOURCES
Who are they?
Compliance
Liaisons


Genesis Centers Operations Oversight: each Center Executive
Director, Regional Vice President, Senior Vice President, and Executive
Vice President of Operations
Genesis Rehabilitation Services & Respiratory Health Services: each
Clinical Operator Area Director, Regional Vice President,
Territory Vice President, and the President of GRS


CareerStaff, Staffing Services: each Area Director/Manager, Staffing
Manager and Operational Vice President, and the President of
CareerStaff
GPS: each Vice President of Medical Affairs, Senior Vice President
of Medical Affairs and the Chief Medical Officer
What do they do?
Compliance
Liaisons



NOTE: Genesis uses
monitoring, auditing,
and/or other
risk evaluation
techniques
to monitor compliance,
identify problem areas,
and assist in reducing
identified problems.




These efforts
are generally focused
on internal operations.

Reviews of contractors
and partners
are completed
as necessary based on
risk assessment and
reported issues.




Comply with and promote adherence to applicable legal requirements,
standards, policies, and procedures, including, but not limited to, those
within the Compliance and Ethics Program, Standard/Code of Conduct,
Federal False Claims Act, and HIPAA
Lead and support the Compliance and Ethics Program within their
management area
Ensure timely and accurate reporting and responses to compliance and
HIPAA-related issues, and monitor corrective action plans related to
issues
Ensure staff participates in orientation and training programs (including,
but not limited to, all required compliance courses and relevant policies
and procedures), and that such training is properly documented
Participate in compliance and other required training programs
Provide access to the Reach Out Line and, within management area, open
lines of communication for compliance issues
Ensure no retaliation against staff who report suspected incidences of
non-compliance
Promptly report concerns and suspected incidences of non-compliance to
supervisor, Compliance Liaison, or, via the Reach Out Line, to the
Compliance Officer
Participate in education, monitoring, and auditing of activities and
investigations
Implement quality assurance and performance improvement processes as
required
Complete performance reviews; determine compensation and
promotions based on the accomplishment of established standards that
promote adherence to compliance and quality standards
Act as Privacy Officer Designee and Civil Rights Compliance Coordinator
for their business area; prepare compliance reports as required
37
THANK YOU FOR DOING YOUR PART TO MAINTAIN THE COMPANY’S INTEGRITY
You are so important to our success! Today, the healthcare industry faces many complex
challenges. We must provide care more efficiently, manage costs, and obey the growing number
of healthcare laws and regulations. Consumers, regulators, and the government are watching us
to make sure we provide quality care and obey the law.
Your compliance with the requirements of this Code of Conduct is critical for the
Company’s continued success. The success of the Compliance Program depends on each of us
and our commitment to act with integrity – both personally and as a Company. It is all of our
responsibility to:




Study the Code of Conduct and information about the Compliance and Ethics Program
Attend required training programs
Comply - at all times – with ethical, professional, and legal responsibilities
Perform our duties as directed by the regulations and standards that govern our
professions.
USE THE REPORTING PROCESS to report any
observation or suspicion of any situation you believe may be
unethical, illegal, unprofessional, or wrong.
Examples include, but are not limited to,






substandard care
altered or falsified medical records
inaccurate claims
improper payments or questionable accounting
internal accounting controls or auditing matters
any clinical, ethical, or financial concern
REMEMBER: If you fail to perform your professional duties or if you suspect a violation and do
not report it, you will face disciplinary action. In some cases, you may even face legal action.
However, you can make a good faith report without fear of retaliation, retribution or harassment.
The company will look more favorably on an employee that reports an error of his or her own.
own.making.
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CODE OF CONDUCT ACKNOWLEDGMENT
I acknowledge that I have received my copy of the Code of Conduct. I have read the Code and have had
the opportunity to ask questions about the Code and my obligation to comply with its requirements. If I
have more questions I will ask my supervisor, another member of management or call the Reach Out
Line.
I understand how the Code of Conduct relates to my position with the Company and I agree to abide by
all Code requirements. I will keep my copy of the Code of Conduct for future reference. I agree to
report Code of Conduct violations that I become aware of in accordance with the Reporting
Process. I acknowledge that my duty to make such prompt disclosure is a vital part of my
responsibilities, and that my failure to report known or reasonably suspected unlawful or improper
conduct may be grounds for discipline or termination of services.
Except as stated below, as of this date I have no knowledge of any transactions or events that
appear to violate the Code of Conduct.
I am aware of the following situations which may be violations of the Code of Conduct:
Print Name
Signature
Date
THE LAW MANDATES THAT YOU REPORT KNOWN OR SUSPECTED INSTANCES OF ABUSE.
FAILURE TO DO SO IS A CRIME. WHEN YOU MAKE A REPORT, YOU ARE ACTING IN ACCORDANCE
WITH THE LAW AND IN AN ETHICAL MANNER
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